Summer

July 30th, 2011
July 29th: Friday Night ALL request dance party from 7 p.m. to 11pm
Saturday Workshops Begin At 9am until 5:30pm – Open Dance From 7pm until 11pm

Featured Instructors:
Simon Ward * Scott Blevins *John Robinson * Carole Daugherty
Jill Babinec * Bob & Denise Boyle * Sharman Toomey

Your Event Host: Mark Cosenza

/ Place:
Crowne Plaza Hotel
5440 N. River Rd. - Rosemont, Illinois 60018
Tel: 1-847-671-6350
Overnight Room Block Available For Fri and Sat Night….
Free Round Trip Shuttle from O’Hare Airport

Summer Line Dance Mania

Registration Form ~ Please use one form per address!

Dancer #1 Name (Please Print)

/

Address

Dancer #2 Name

/ City/State/Province

Daytime Phone ( )

/ E-mail Address #1

Evening Phone ( )

/ E-mail Address #2
Item & Description / Before July 1 / After July 1 / QTY / TOTAL
Event Pass: Admission to ALL workshops, Evening Open Dancing (both Friday & Saturday) and free video pass! / $60 ea / $70 ea / $

Friday / Saturday Night Dance Only (If only attending one night, circle the night of choice)

/ $10 each night / $10 each night / $

Saturday Workshops / Night Open Dance Only

/ $50 ea / $60 ea / $

I, the undersigned, for myself, my heirs, executors and administrators, hereby waive and fully release and agree to hold harmless the "SUMMER LINE DANCE MANIA" workshop weekend, its organizers, employees, and their agents harmless from any and all lawsuits, claims or demands of any and every kind and character arising from andin connection with this Event, whether as a spectator, staff member, or attendee. I understand the physical risks of social dancing and assume full responsibility for any injury or personal damages resulting from the " SUMMER LINE DANCE MANIA " workshop weekend. I hereby authorize the reproduction, sale, copyright, exhibition, broadcast and / or distribution of any event videotape and photographs of me during all the accompanying activities on JULY 29 – 30, 2011 without limitations. I certify that I am 18 years of older (application to Legal Guardian if under 18 years of age.)I understand and acknowledge that NO REFUNDS will be issuedunder any circumstances.

Dancer #1 Signature: ______Date: ______

Dancer #2 Signature: ______Date: ______

Method of Payment - NO REFUNDS
[ ] Check or [ ] Money Order made payable to MARK COSENZA [ ] Online Payment Via Paypal
Note: Cancelled check / money order receipt is your receipt. There will be a $20 charge for returned checks. Credit Card purchases may be charged online by going through link at Website
OnlineCredit Card/Paypal payees must complete the online registration form at . / Form must be filled out and signed by person named.
Mail registration with payment to: Mark Cosenza
5512 N. Normandy Avenue Chicago, IL 60656
Questions / Information,
Email Mark through his website at